Easy as ABCDE...

The Blog went well past the 500 hits today so thank you all, it’s good to know people are interested in our little adventures.

We had quite a full but also productive day yesterday. We'd prepared an afternoons worth of presentations and practice scenarios on approaches to the recognition, assessment and early management of the sick/unstable patient. This was very much aimed at the junior doctors here, but there were a lot of consultants from the different specialities there too, probably around 30 in all.

Starting with A...

Overall the afternoon went really well. We were just teaching the real basics (the ABCDE scheme, Airway, Breathing, Circulation, Disability, Exposure) which hopefully will provide a good foundation for all that comes next from us and others. We made the lecture style quite interactive which they really warmed to. (I get the impression that the usual method of medical education is much more formal...)

Physiology of circulation

At one stage I demonstrated the scheme in real time on a model patient (Dave) and the challenge was that I had to detect the pathology the audience had picked for him, and unknown to me. This lead into a section to round things off where we ran a few simple ALS/ATLS style practice scenarios in small groups to check they could put it into practice. To be honest this had somewhat of a mixed response – everyone tried which was good and some did well, but some of the doctors (at SHO level) really struggled. If normal undergrad teaching is formal / by humiliation and an interactive lecture is rather radical I reckon the concept of actually role playing scenarios was way out of their comfort zone which may have been part of the problem. Medical education is challenging even within a cultural framework that’s very familiar, let alone trying to address the issues of cross-cultural contextualisation. It does however pose us the interesting question of how do you make it even simpler than ABCDE? (That’s not a rhetorical question by the way, I’d love to hear suggestions.)

O2 applied, the patient feels much better. Capillary Refill is normal.

I think it all adds up to the realisation that these things are going to take time, hard work, perseverance and patience. None of this should come as a surprise really, so I suppose we’re just going to have to stick with it re-emphasising the basics, and try to provide positive role models in the way we go about our clinical work.

Overall as I mentioned the whole thing went down really well. I think it helped show them that we were serious about being here and the contributions that we can make, even as non-specialists. The consultants in particular absolutely loved it, and want to make it a weekly Saturday afternoon inter-departmental teaching session, so I think we’ve just inadvertently started Grand Rounds in JTH!

James

A few odds and ends

Life is treating us well in Juba. We're working hard of course, but it's great fun. One of the medical elective students had a birthday the other day, and we all went out in the evening for food and beers with a bunch of other ex-pats from various NGOs. I actually had a very decent burger! There are some (admittedly expensive) but pretty nice places to eat out here. Obviously Dave and I have to do a little more exploring to find them all...

Below are a couple of interesting bugs we've found, both rather large.

Today Dave and I are making our formal teaching debut at JTH running a few sessions for the house officers on the recognition and early management of unstable patients, just the basic ABCDE stuff really. The Brothers here actually have a video projector which they're kindly lending us, for the day. (JTH doesn't have one, but it would be really educationally useful if anyone has a spare...!)

Naturally last night we had to test the compatibility... :o)

I've finished collecting and analysing data from the first round of an audit we did last week, and there are some really interesting results. I have to write it all up, but more on that later.

Bye for now

James

Trauma

Trauma is a really big problem here in Juba. I’d say gun-shot wounds and RTA’s make up the bulk of our acute surgical takes most days. (Here surgery and orthopaedics are all one.) In fact, they experience what we would call a “major incident” at least once a month! These usually take the form of mass road accident casualties etc.

Well we had the first one of our trip last night. There was some tribal conflict (cattle raiding I believe) in one of the rural regions three hours out of Juba. This actually occurred three days ago, but the bus load only arrived today to JTH. There were about 20 dead, 50 injured. The majority of these were gunshot wounds and lacerations including, sadly, women and children with bullets lodged in various places. Amazingly, most of the patients were haemodynamically stable (I assume because the sicker ones had already died) but we still took 15 to theatre this afternoon on the trauma list. Generally surgical debridement was the order of the day (wounds three days old were by now horribly infected) along with fishing out the shards of bone shattered by bullets and fixing the fractures. I’ve never seen actual bullet injuries in the UK and I hope I never have to. They’re horrible.

There’s certainly a lot of challenges to meet in the acute care here, (especially given the volume every day and frequent major incidents) but we’re making progress. Obs and drugs charts are being printed by the MoH. The seniors here recognise the need and are supportive of our efforts, which is very encouraging. We’ve been given an office for the link on site. We’ve set out a teaching programme on some of the basics of assessment of the sick patient, which we begin on Saturday. We’ve completed the first cycle of an audit assessing the quality of the acute care. We’ve indentified a suitable ward to setup a rudimentary A&E Resus, and are currently looking at different models of triage.

There’s a lot to do, but there are so many opportunities out here: it’s brilliant. The hospital’s really moving forward and it’s exciting to be a (small) part of it. And the weather here is beautiful!

James

A doctor's life with 500 new patients a day

Good evening everyone. I thought it was about time I made an entry on the Blog following an email from various individuals demanding an “Attwood-esque” installment. Well here it is...

Now I used to work at an A&E department when a busy day was 140 admissions. On my first day I went to the outpatients department and was greeted by this:



The day carried on in a similarly unusual manner as James has alluded to on his correspondence. Suffice to say my first day was a culture shock. However, many lessons were learned including the importance of coming to the hospital with toilet roll on your person.

Being of a medical persuasion, I find this place fascinating. It is literally alive with pathology and I have seen things that I have never seen before. Cerebral malaria, TB, HIV, more ascites than you can shake a stick at, splenomegaly, hepatomegly, and proximal myopathy. Yesterday I diagnosed my first ever diastolic murmur possible caused by mitral stenosis and today I saw a case of tetanus- just like in the textbooks! (sorry about this paragraph, all of you non-medics)

Sad things are seen here too. A 22 year old man came in with cerebral malaria and despite our best efforts we couldn't stabilise him. He presented too late and died later on that day. In St Mary's he would have been for full escalation of treatment and would have been ventilated on intensive care. He was a student at Juba University, no older than the medical students we have here with us from Southampton.

Sometimes the problems here seem so big that if you think about them all at once everything seems so impossible. However, the Southern Sudanese are the most inspirational people. After a war lasting 40 years, they remain optimistic and are working hard to re-build their country. Juba has already changed since I visited in March. The main roads in Juba are now all tarmacked and there are pavements, too. New housing is being constructed and buildings are constantly going up.

Things have changed in the hospital, too. It now has power 24 hours a day and has a new health resource centre with 8 wireless computers and a load of laptops. On my first day there was a computer course and they were being taught how to use Microsoft Access!

These people are truly remarkable. They are tenacious and optimistic in life and they are very industrious. They have interesting mannerisms that I am still learning. Everyone shakes hands here. If you see someone you know, you shake hands. If you see someone you know well, you slap your hand into another person’s hand before shaking it vigorously. It is common for men that are good friends (in the platonic sense) to hold hands whilst walking. This happened to me once which was... novel.

The staff here are very optimistic about the St Mary’s Juba Link. Yesterday we had a Link Committee meeting and they were so kind, complimentary and accommodating- it is this and their hard-working attitude to life that gives myself and James the desire to keep working alongside them. I only hope that we live up to their expectations.

I don’t want to tell you everything. I think little instalments are much better than one long email. So I shall sign off for now and tell you a bit about the culture in my next update because this in itself is fascinating. I leave you with a photo of me and James beavering in his room and another photo that we took for teaching this Saturday, where we try and demonstrate how scary it could be to take care of the sick patient if you know nothing!

All the best, team. Bye for now.

David

Whoops

I had a little problem with my bathroom today. (Not my fault I hasten to add!)

The Brothers here all have different skills, and I'm waiting for the DIY Brother to fix it for me. I'm going to be late for work though...

James

Our trip objectives

Hi there.

We’ve been observing emergency and routine ward work for a couple of days now, so I thought it was about time I discussed some of the professional aspects of our stay here.

Our role here is still developing, but over the past few days of clinical observation, discussions and meetings with the seniors here in both medicine and surgery, a few common strands are emerging. In brief, we feel that the main way we can be of use here is in the teaching and training of the junior doctors, both in formal settings and by modelling our approach to them in our clinical work.

There are several issues to be addressed, but one of the most important is the quality of emergency care (medical and surgical) delivered in the acute setting. It would be useful at this stage to describe the current system:

Description of the Accident and Emergency department
The outpatients department has become one of Juba teaching hospital's biggest challenges. It functions as an Accident and Emergency, Outpatient Department and Primary Healthcare Clinic all rolled into one. However due to the sheer volume of patients (around 500 attend the unit every day) there are serious problems with fulfilling its roles.

There is a central seating area in the middle with disabled access that is flanked by the pharmacy, laboratory, and X-ray dept. In front is the Emergency Ward with 9 Emergency beds. There are no fluids, giving sets, cannulae or drugs. In the top right hand side and to the right are 6 small consulting rooms about 3m x 3m (some smaller). Medical Officers (SHO equivalent) from the specialties Pads, O&G, Medicine, and Surgery sit here and interview patients

A&E/OPD

How the department functions
There is no triage. Patients book themselves in at reception and depending on their presenting problems are sent to various specialties by an untrained receptionist. For example if the patient has a limb problem then they are sent to the surgeons. This system is often inaccurate. Worse still, sick and unstable patients are not being recognised. David described on his first visit how poorly patients, lying on the floor, were stepped over so that well patients with minor complaints were seen. He also found a patient whom no one knew, who hadn’t been seen by a doctor, had died on an examination couch.

From a surgical perspective, my observations have been very similar; the other day I went to the department and found three or four poly-trauma patients lying on and bleeding all over the floor unattended, one with a clearly fractured humorous. The doctors on duty at the time were in the office seeing the patients with hernias who registered first in the queue.

Part of the problem is the actual structure of the department, particularly the lack of triage. The doctors are very over-stretched given the sheer volume of patients they are seeing, and this is something we’ll be looking into helping to alter in the future.

Another issue is the acute care delivered to the emergency admissions in the medical and surgical assessment units. Basic observations are generally not completely done, history and examination documentation are usually rather scanty, and there seems to be an inability to distinguish and prioritise the haemodynamically unstable patients.

David in part of the MAU

David and I see one of our key roles here as teaching the house officers how to improve their basic skills in the recognition, assessment, basic management (including documentation) of the sick patient. We’ve a few things in mind including:

• Organising formal teaching sessions to run over and reinforce the very basics of the ABCDE approach, including the necessity of measuring the basic physiological parameters, basic fluid management, when to call for help etc.

• Basic training on the importance of documentation

• The introduction of Obs charts, fluid charts etc. (Currently there are none.)

• Look into the restructuring of the A&E/OPD to include a triage system so critically ill or deteriorating patients aren’t unnecessarily left in a queue

• Audit the current system of recording and responding to obs on admission (and identifying and responding to the haemodynamically unstable) then re-audit after training/introduction of obs charts

• Model the approach to the House officers in our own clinical work and notes

Naturally there are plenty of other things to get on with now, but I think if we could just lay a bit of a foundation in these simple things we could make a really positive impact, hopefully with improved patient outcome.

I’m sorry if this was a bit of a long post but thanks for sticking with it. We’ll be keeping you updated on how it all pans out but I hope this sets out some of the big picture to put the rest of it in context. As I said, our role’s still emerging...


James (& Dave)

PS I promise the next post will have less text and more pictures!

Some Hospital Photos

This is the road to JTH which we make twice a day. (This is the main hospital gate just coming up at that white sign post)

Here are some of the hospital buildings. Each ward is in a seperate building so it's more spread out than our hospitals.



This is looking back at the main gate from inside the compound.


Some more wards...



And finally a rather nice lizard I found on the way home this evening.

I hope these put you in the picture a little more about the place. The climate is hot and humid, but generally sunny and the country around is very green. I recall the Indian Monsoon being far more humid and generally unpleasant so all in all it's pretty good.

Dave and I had a very positive meeting yesterday with our bosses here to plan out what we aim to do and what they'd like of us, and luckily the two were pretty congruent. We're pretty excited about the opportunities here, but more of this at a later date. Needless to say they were very welcoming and supportive and it looks like we should have a really useful time here.

Bye for now

James

Life in Juba

Good evening.

I note that the previous post was rather text heavy, so I thought to break it up a little bit I'd include some basic photos....

Below is my room in the monastry, which although sparse is roomy and comfortable, complete with en suite. The shower is cold or cold, but in this climate is rather nice.


I'll stick up some shots of the hospital in a little while (the upload process with this internet connection is rather tedious!)

James

Safe Arrival

Hello there

Just to let you know I've arrived safely in Juba. It took a while longer than intended due to a flight delay (7 hours) in Addis. It's not a huge airport, so I became quite familiar with the place. The airport did give us a free lunch. This included some sort of meat dish - I'm not sure entirely what is was but I definitely caught site of a cross-section of vertebrae in there, so I politely declined. The rest of it was very tastey.

Anyhow, myself (and importantly all my baggage plus one undamaged yet very out of tune baby taylor guitar) all arrived ok and I was met by the guys here, so no worries. We appear to be staying in a catholic monastry of some kind. Lots of people there called "Father" who are all very nice. Accommodation is realatively good and the food appears well above average!

I'm still rather tired by it all but generally very excited to be here. No GI upsets so far...

When David and I formulate a masterplan and mission objectives for the trip I'll post again. The internet is intermittent and can be painfully slow, so I'll have to see how it goes uploading photos. I'll do my best as they're far more interesting for you.

Comments / emails always very welcome.

James

Welcome

Hello there everyone and welcome to our Juba blog...

This is just a little post by way of introduction - this blog is intended to allow friends, family and those generally interested to keep track with our progress, and hopefully should be a little less formal than some of the other publications. We'll also try to put lots of nice pictures up as well.

It's been a stressful week getting everything ready to live and work in the Southern Sudan for the next 4 months, but at last everything is sorted. Dave flew to Juba on Friday and has arrived safely. I've been held up in visa-related logistics and hence am flying this evening.

Save to your favourites now and keep checking how we're doing! We'll both really value the support from all of you back home.

James